Wide variability in the quality of colonoscopy is due to patient characteristics, physician characteristics, and success with implementing interventions to improve the quality of colonoscopy. Inadequate bowel preparation is a critical quality of care issue in about 30.2% of patients who undergo colonoscopy because it can lead to substantial costs in rescreening and a per adenoma miss rate of 47.9%. Patients insured by Medicaid experience higher risk for inadequate bowel preparation partly due to bowel preparation instructions that are formatted for high literacy groups. Randomized controlled trials have found that splitting the dose of bowel preparation over two days rather than taking the dose in one day and using low literacy education for bowel preparation rather than education for higher than 6th-grade literacy can significantly improve the adequacy of bowel preparation. The next step in translating this research to practice is to conduct pragmatic studies of the effectiveness and cost of these interventions and to identify factors that influence the implementation of these interventions in endoscopy settings. This proposed study compares the effect of split-dose bowel preparation versus split-dose bowel preparation plus low-literacy education on adequacy of bowel preparation and adenoma detection for patients receiving colonoscopy in five outpatient endoscopy settings, with more than 30 physicians, and 60 staff (AIM #1). We will also conduct formative research on the aspects of endoscopy setting that determine success with implementing these interventions (AIM #2). To accomplish AIM#1, we will use segmented regression analysis of cross-sectional interrupted time series data for approximately 10,000 patients to compare the change in adequacy of bowel preparation and adenoma detection for the two study groups from before to after implementation of the interventions, for patients overall and for patients with Medicaid insurance versus other insurance. To accomplish AIM#2, we will survey physicians and their staff prior to implementing the comparative-effectiveness intervention to learn about their readiness to implement the interventions (e.g. leadership, culture, systems for facilitation, and perceptions of the evidence), and we will survey patients before and after the comparative-effectiveness study to learn about their change in experience with pre- colonoscopy education. We will also measure implementation outcomes (i.e. fidelity, dose, and cost) at the end of the comparative-effectiveness study. Our analysis for AIM #2 will examine the relationships between readiness to change and implementation, patient and colonoscopy quality outcomes. This research will inform stakeholders about which interventions are most effective and which aspects of endoscopy settings are most influential to improve colonoscopy quality. Therefore, our research has the potential to make a major impact on implementation science, reducing cancer inequities, and colon cancer control research.